Locum-Tenens and Permanent Employers/Agencies Request Services

Contact Name:	*
Contact Title:	*
Facility Name:	*

Phone Number:	(111-222-3333) *
E-mail:	*
Your WEB Site:
Type of Facility:	Select Type of FacilityHospital BasedHospitalist-Managed CareManaged Care PositionHMOPPOClinicOutpatient ClinicGroup PracticeIndividual Private PracticeMulti-Specialty GroupSingle-Specialty GroupBioTechnical/BioMedicalPharmaceuticalPharmacy, RetailClinical ResearchAcademic PositionAgencyOtherUnknown*

Brief Description: (Coverage needs: perm or locums, date begin date ending)	*
Recruiter Services:	Does your Org. work with outside recruiting firms? Yes No
Have you used Locum Tenens Before? Yes No

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